Health-Related Quality of Life and Primi-Gravid: A Comparative Study of Natural Conception and Conception by Assisted Reproduction Technologies (ARTs).

BACKGROUND
Childbearing for the first time is a unique experience. Quality of life is an important indicator in health studies. This study aimed to assess the quality of life of women who were conceived by ARTs and had successful childbirth for the first time and to compare it with quality of life in women who become pregnant naturally and similarly had successful childbirth for the first time.


MATERIALS AND METHODS
This was a cross sectional comparative study. The accessible sam- ple was recruited from patients attending an infertility clinic and two obstetric and gynecology clinics in Tehran, Iran, during March 2010 to March 2011. In all 276 patients were approached. Of these, 162 women (76 women in natural conception group and 86 women in assisted reproduction technologies group) who met the inclusion criteria were entered into the study. Quality of life was assessed using the 36-item Short Form Health Survey (SF-36). Women completed the questionnaire at two time points: i. last trimester and ii. first month after delivery. Comparison was made between two groups using Mann-Whitney U test and paired samples t test.


RESULTS
Comparing the SF-36 scores between women in natural conception group and ARTs group before childbirth, it was found that natural group had better condition on physical functioning, role limitation due to physical problems, bodily pain and social functioning, while the ARTs group reported better status on general health, vitality, role limitation due to emotional problems, and mental health. However, after childbirth, the ARTs group reported a better condition almost on all measures, except for physical functioning. Comparing differences in obtained scores between two groups before and after childbirth, the results showed that improvements in health related quality of life measures for the ARTs group were greater in all measures, expect for general health.


CONCLUSION
The findings from this study suggest that health-related quality of life was improved in women who became a mother for the first time by either method. Comparing to women who became mother by natural conception, women who received ARTs showed better quality of life from this first successful experience.


Introduction
First pregnancy is a major event in woman's life. Changes in physical appearance, feelings related to motherhood, and family expectations are among challenges that might primigravida women experience more often. Thus, studying health-related quality of life in this population would be worthwhile either when pregnancy occurs naturally or when happens by assisted reproduction technologies (ARTs).
In addition of computation of morbidity indicators, incidence and prevalence rate of diseases and fertility rates, for health assessment and evaluating of the health involvement presently another factor added to the indices of health, is the quality of life (1, 2). Quality of life is an important indicator in health studies in order to be considered as fundamental information and to be ascribed at the time of evaluating interventions (2, 3).
There is a number of studies assessing quality of life of female population indifferent parts of world in related to fertility (4-10) or to different methods of delivery (11-15); however, studies evaluating health-related quality of life among infertile women who became pregnant by ARTs for the first time and had successful childbirth are scarce. In general, the findings of different literature suggest that health-related quality of life in infertile women is suboptimal (15-19), while they might suffer from a poor psychosocial health (20-25), and with regard to the type of delivery, there is no evidence of a clear-cut finding in favor of a given mode of childbirth (11-15).
Child-bearing is one of the most painful procedures that a female is likely to experience. The ceed the extreme illness situation (26). Primigravipainful (27).
The objective of this study is twofold. Firstly, we assessed the health-related quality of life scores in women who become pregnant by ARTs and had successful childbirth for the first time, and secondly, we compared obtained scores in health-related quality of life between aforementioned group and women who become pregnant naturally and similarly had successful childbirth for the first time.

Design and the study samples
This was a cross sectional study of primigravida women in order to compare health-related quality of life between those who had natural conception and those who received ARTs. The women were recruited from the patients attended Royan Institute and two obstetric and gynecology clinics in the north and south of Tehran, Iran, during March 2010 to March 2011. The recruitment of patients from two different settings was due to the fact that we intended to include women with different socio-economic backgrounds in the study.
Accessible samples were selected if they were aged between 20 to 35 years old, experiencing Iranian. They completed the study questionnaires month after childbirth.
Women with postpartum depression, disability or chronic illness, multifetal, miscarriage, stillbirths, neonatal period death and infant anomaly were excluded from the study. In addition, due to high risk pregnancy for those who became preginclude this age group in the study.
Based on results of a study by Nilforooshan et difference between two groups regarding quality of life, the sample size was calculated by the following formula, and a sample of at least 65 women A study with such a sample size would have a However, in practice, a consecutive sample of 276 patients was approached. Of these, 162 women (76 women in natural conception group and 86 women in assisted reproduction technologies group) met the inclusion criteria, and were then entered into the study and completed questioner before and after childbirth.

Measures
Health-related quality of life (HRQL) was measured using the Iranian version of 36-item Short Form Health Survey (SF-36). SF-36 was constructed to survey health status by John Ware in 1992 (28), while the Iranian version of the questionnaire underwent a rigor psychometric evaluation by The Institute for Health Sciences Research (IHSR) and showed that it is a reliable and valid measure of health-related quality of life in Iran (29).
"Reliability was estimated using the internal consistency, and validity was assessed using known-groups comparison and convergent validity. In addition factor analysis was performed. The internal consistency (to test reliability) showed that all eight SF-36 scales met the minimum reliability standard, the Cronbach's exception of the vitality scale (alpha=0.65)" (29). education, employment, and previous treatment for infertility were also collected in a separate form.

Statistical analysis
data. For comparing categorical data, chi-squared test was used, while t test and Mann-Whitney U test were used for group comparisons. The Wilcoxon two related samples test was used to compare the mean values for before and after childbirth assessments. A Statistical Package for the Social Sciences (SPSS; SPSS Inc., Chicago, IL, USA) version 13 was used for data analysis and a P value less than 0.05 was considered The Ethics Committee of ACECR (Iranian Academic Center for Education, Culture and Research) approved the study. All patients gave oral consent for the study.

Results
The characteristics of women are shown in table 1. The response rate was about 59% and the mean age paring the SF-36 scores between women in natural conception group and ARTs group before childbirth, it was found that natural group had better condition on PF, RP, BP and SF, but the ARTs group reported better status on GH, VT, RE and MH. The Results are shown in table 2. However, after childbirth, the ARTs group reported a better condition almost in all measures, except for physical functioning (Table 3).

*; Derived from t test and **; Derived from chi-square test.
Ahmadi et al.  Finally, in comparison of scores between two groups, before and after childbirth, the results showed that improvements in health related quality of life for the ARTs group were greater in all are shown in table 6.

Discussion
This study reported on health-related quality of life in a group of women who became mother ARTs. In general, both groups showed improvement in health-related quality of life after successful childbirth.
It seems that the ARTs group reported more benefit from being mother for the first time. Since the ARTs group was not sure whether they would have had a successful childbirth, when the procedure was successful and they became a mother, they indicated a greater improvement. In addition, the successful childbirth for women in the ARTs group might be seen as the end of stigma surrounding infertility. Evidence suggests that infertility is a constant reminder of inability to conceive (32). It is argued that infertility not only impose pressure on women themselves, but also it makes several difficulties for them in the social world including presenting their life story to others and the justification of why they desire to become a mother (33). However, it should be noted that after successful ARTs, quality of life might be improved; otherwise, such interventions might transform infertility from a private pain to a public and prolonged crisis (34, 35).
Also, our own experiences in ARTs clinics suggest that these women receive more support from their partners. In fact, ARTs is the couples' common efforts to have a child, and thus, these women report better psychological health when they become a mother. It is argued that the good mental health among women and men undergoing ARTs may simply reflect their satisfaction with successful treatment and fulfillment of their hope for parenthood (34). In addition, as noted by Repokari et al. (36), lack of mental health symptoms in women who experience a stressful period of infertility treatment, could be explained by ego defence mobilization, which could be considered as an interesting subject for future study.
role physical, bodily pain, social functioning and aspects of both physical and mental components Perhaps, as discussed earlier, infertile women experience less stress and better global life quality after having a baby than their fertile controls (37).
In order to understand the extent to which the experience of successful childbirth could improve quality of life in infertile women, we compared quality of life in women who received ARTs and those infertile women who became pregnant spontaneously during their life.

Conclusion
The findings from this study suggest that health-related quality of life improves in women who became a mother for the first time by either ways. After Comparing two groups, our findings revealed that women who receive ARTs might show more benefit from this first successful experience. The results of this study would serve as baseline data to assess the health of pregnant women. Perhaps, this could be investigated in the future studies, while it is noted that the results should be adjusted for confounding variables.
A group of participants in this investigation were infertile women who had become pregnant after infertility treatment, so the results cannot be generalized to infertile women who have not been treated yet. Unfortunately, since the distribution of our data was not normal, we could not adjust should be interpreted with caution.
It is suggested to conduct further studies on the mothers' quality of life in the months following childbirth in order to evaluate breastfeeding and infant feeding conditions. 17.
ity of life and its different domains in fertile and infer-